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HomeMy Public PortalAbout6022-6028 KAUFFMAN AVE_Sewer__ F \41RKERS'C:-OMPENS'`NON DECLARATION 92-0002 DPW 3/87 `l��� I hereby' aft(rr that I Piave a certificate of consent to self 76A642D insuf of 4 certificote of Workers'Compensation Insurance, or CE eoa a certifiecfjco y thereof (Sec. 38/Ly}hC.� APPLICATION FOR PERMIT Policy No.E`1(1,( Company es ❑ SEWER - SEWAGE DISPOSAL Certified copy is hereby furnished. ❑ Certified copy is filed w/itht cou ty ding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dep tmeiin���.y� Date 0zApplica FOR APPLICANT TO FILL IN CONNECTION DATA CER(IFICATE OF EXEMPTION FROM WORKERS' BUILDING DATION DEPTH COMPENSATION INSURANCE ADDRESS �— (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOC ITY LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. A= Z Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as to become subject to the Workers Compensation Laws. OWNER ` CO.IMP.NO. JOB NO. MAIL ADDRESS S TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant Iy y� r AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY , �c.�(,,KA.41 TEL.NO. (-- Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHWIT 6ewe LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. —�� c SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES rvs and Professions Code, and my license is in full force and e.�:eCt. CONTRACTOR NECTION CHARGE FEE License Number ] Lic.Class— ADDRESS­ REIMBURSEMENT FEE 0. • DISTRICT NO. GROUP MAP PROCESSED BY 0 Co°ntractc�tt�1 j.i under Sec. of the L.A.Co.y— +CRc. CI E . U PG ❑ I am exemptSTATE �. { UC. p LICENSE NO. tom` CLASS SG Plumbing Code and/or Sec. of the NO. DE � FEE FINAL V OUSE SEW CON ECTI G O DATE �B VALI ATIONUJ B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD e HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature f CONNECT ADDITIONAL BLDG.OR NER-BU DER DECLARA ION WORK TO HOUSE SEWER n n OVERFLOW SEEPAGE PIT,DRAINFIELD A-9 0 6'1 A Thereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE L�for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE { 0 0 0 0 0 {essions Code): SEWER OR DISPOSAL SYSTEM PI,as owner of the property,or my employees with wages as ° o27,50 their sole compensation, will do the work and the structure _ is not intended or offered for sale (Section 7044, Business ° ° ° 2 7. 5 0 c% and Professions Code). OWNERS Permit $ (] I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE G 2 2 6 0 8 8 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 4 t , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF I9 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AG i ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances an .State laws egulating Plumbing and Sewers, and by thor'ze repr entatives of this County to enter Ur the ob ve ent'`ne roperty for inspection p rposes. Ig e f Permittee /� ate �� SEE REVERSE FOR EXPLANATORY LANGUAGE c- WORKERS' COMPENSATION DECLARATION 'f 92-0002 DPW 3/87 affirm that I have a certificate of consent to self 76A642D insure, o, a certificate of Workers'Compensation Insurance, or a certified_ opy thereof (Sec. 3800, Lab C.) APPLICATION CE 808 APPLICATION FOR PERMIT `Policy No. i 1PI Company!! tiv-�Tl/11� _ Os ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the unty buildi i pectin COUNTY OF LOS ANGELES BUILDING AND SAFETY depa tment. Dated Applicant TFPPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS' BUILDING a � DEPTH .'r COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the MANHOLE REFERENCE 315V,&1 uPPE permit is for one hundred dollars ($100) or less.) LOCALITY ( LOWER' I certify that in the performance of the work for Which this CROSSNEARENEARESST TYPE OF CONNECTION LENGTH FROM Y. UR P.L. M,L.TO P.L. permit is issued, I shall not employ any person in any manner �j so as to become subject to the Workers' Compensation Laws. OWNER CO.IMP.NO.✓J`04y) POB NO. MAIL + `� ).� TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS I n �% NOTICE TO APPLICANT: If, after makingthis Certificate of _��`f� , ' AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY cLi/�.� '— �,,�.��-G�TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. I.Y.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMEN LICENSED CONTRACTORS DECLARATION No.OF BLDGS. PERMIT NO. S. ��� SIZE OF L NOW ON LOT 1 hereby affirm that I am licensed under provisions of Chapter USE 9 (commencing with Section 7000) of.Division 3 of the Busi- gull CHARGES ness and Professions Code, and my license is in full force and effect. _ CON RACTOR CONNECTION CHARGE FEE License Number t' LIC.Class l.—> �'� , MBURSEMENT FEE O .{r�� DISTRICT NO. GROUP MAP PROCESSED BY V Contractol Y_,-_�� Date C L �j-� BK PG STATE 2� LIC. "'ll �. w Q ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. .D LIC. ✓ QJ Tji_ f✓, 0 Plumbing Code and/or Sec. of the NO PUBLIC SEWER DU SEWER C NN CTING TO DATEFINAL VALIDA ION LLJ B. & P. Code for the following reason 1 N SEPTIC TANK,SEEPAGE PIT OR FI PITS AND/OR DRAINFIELD ate BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Slgnatur CONNECT ADDITIONAL BLDG,OR OWNER-B ILDER DECLA ATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property,or my employees with wages as z 9 0 5.8 A their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business # o 0 0 0;� 0 and Professions Code). OWNERS I Permit $ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE ..I o o27,50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO = Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - 275 U CONSTRUCTION LENDING AGENCY �'�/ I hereby affirm that there is a construction lending agency SIGNED THIS �? � AY F I9� , o226-88 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. ag a to comply with all County ordinance d St to law gu ting Plumbing and Sewers, anrh auth ize r r ent t ves of this County to enter upbove- enti ed Top ty for inspection purp es. Signature of Permittee Dat �,(/ SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'.COMPENSATION DECLARATION affirmr that I have a certificate of consent to self 76A642D DPW 3/87 Insure, r a certificate of Workers'Compensation Insurance or 6A64211 } a cerilfiedthereof Sec. 380 a CE BOB A PLICATION FOR ERMIT Policy No. �m Company,� Os El Certified copy is hereby furnish SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed wit eco my ui ding s coon COUNTY OF LOS ANGELES BUILDING AND SAFETY depa tmen . DateApplicant FOR APPLICANT TO FILL IN CONNECTION DATA CERT FICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER ST permit is for one hundred dollars ($100)or less.) LOCALITY LOWER I certify that in the performance of the Work for which this CROSST TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ any person in any manner f V. CURB P.L. M.L.TO P.L. so as to become subject to the Workers' Compensation Laws. P.C.NO. OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO, Dare Applicant ADDRESS NOTICE TO APPLICANT: If, after makin this Certificate of j j `�,[ G AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY TEL.NO. "`1 1 V v dj Exemption, you should become subject• to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter usEOF t 9 (commencing with Section 7000) of Division 3 of the BUsi- BUILDING CHARGES ness and Professions Code, and my license is in full force and effect. j. CONTRACTOR C NECTION CHARGE FEE License Number�}77�Z1�1" LIC.CIOSs \ / I URS MENT FEE CL CL ADDRESS Controctor4ti�t `��� ate SJ y, a DIST CT'NO, GROUP MAP PROCESSED BY O CIT ❑ I am exempt under Sec. of the L.A.Co. L PG E uc. 5 �� � BK I Ci p P LICENSE NO. CLASS b Plumbing Code and/or Sec. of the N�' FINAL V HOUSE WER CONNEC G T DATE --� VALID TIONLU PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINA PITS AND/OR DRAINFIELD Dot HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BU R DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD O I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Sectors 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM El 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure ° 1 54,00 is not intended or offered for sale (Section 7044, Business o 0 1 5 IL 0 Q 61 and Professions Code). OWNER'S Permit $ ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE , 0226 0 88 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY t9 � 00I hereby affirm that there is a construction lending agency SIGNED THIS DAYDAYO for the performance of the work for which this permit is OWNER OR OWNERS AG issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County enhe nd• State laws regulating Plumbing and Sewers, u orize r r tatives of this County to enter v me d pr perty for inspection purpso+ses. 1el � . ignature o Permitte D to SEE REVERSE FOR EXPLANATORY LANGUAGE ,,,4f, ;11 O�1/�� WORKERS'COMPENSATION DECLARATION w affirm,that I have a certificate of consent to self 92-0002 DPW 3/87 insure, or a certificate of Workers'Compensation Insurance, or a 76A642D a certified co�f (Sec. 38091110b .) CE 808 APPLICATION FOR PERMIT Policy No. Company 4- ©s El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL. ❑ Certified copy is filedwith th county wilding ' sp 'ion COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date I I&S Applican FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS' BUILDING O .2, 1L �0—����`�� STATION DEPTH COMPENSATION INSURANCE ADDRESS — (This section need not be completed if the work involved by the LOCALITY �— MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) certify that In the performance of the work for which this CROSSNEAS Y TYPE OF CONNECTION LENGTH FROM CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner �I so as to become subject to the Workers' Compensation Laws. owNER — CO.IMP.NO. JOB NO. MAIL ') C 1 �( '_ L 9 p � TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS Ci J v v —�.c� . NOTICE TO APPLICANT: If, after makingthis Certificate of L4 U - AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY ;, TEL.NO. `L. —1 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT 10 STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. _ �S J Q I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTUSE OF �� D 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR ONNECTION CH GE FEE License Number ���Sy LIC.Class ADDRESS FEE O Contractor V Y1.L eYyl�Date DISTRICT NO. GROUP MAP PROCESSED BY 0 CIT STATE LIC. BK PG ❑ I am exempt under Sec. of the L.A.Co. L3� Ii O P LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO HOUSESEWERON ECTI G O FINAL VALIDA ION LU 'r IL V) B. &'P. Code for the following reason PUBLIC SEWER N SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL yDate HOUSE SEWER CONNECTING TO BY / PRIVATE DISPOSAL SYSTEM Signature .� CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure 9 Q 5 9 A is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit o S AUTHORIZATION # ° °'1 O ❑ I,as owner of the property,am exclusively contracting with TOTAL FEE S licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ° - 27.50 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY �+ ° ° - 2750'u SWNER O HIS _�Dfyl / 19 ► I hereby affirm that there is a construction lending agency 1��.//�--- for the performance of the work for which this permit IS OWNER OR O 226-88 issued (Sec. 3097, Civ. C.). OWNERS AGE ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. agree to comply with all County ordinances and State la Is r gulating Plumbing and Sewers, and reby uthoriz r :e tatives of this County to enter upo a ab a-me tion d p perty for inspection purposes. of Perm ittee' D SEE REVERSE FOR EXPLANATORY LANGUAGE 15p. �44- —Q f WORKERS, COMPENSATION DECLARATION affirmthat I have a certificate of consent to self 92-0002 DPW 3/87 F'. a su,e, ur a certificate of Workers'Compensation Insuranc or 76A642D cerfified cop thereof (Sec. 380 C. CE 808 APPLICATION FOR PERMIT Policy No��y I to Compan ©s , El Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county buildin i spec on COUNTY OF LOS ANGELES BUILDING AND SAFETY depa tmen . Date �� 3O Applican 7 FOR APPLICANT TO FILL IN CONNECTION DATA CER FICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS0 z STATION DEPTH (This section need not be completed if the work involved by the NHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER NEARES TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS T. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. P.C. NO. I P OWNER CO.IMP.NO. JOB NO. Date Applicant MAIL'AD IL TRUNK PERMIT NO. ROAD PERMIT NO. �v/ NOTICE TO APPLICANT: If, after making Certificate OCITY TEL.NO.this f AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE � (�J r Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed a� revoked. BLOCK TRACTS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter TSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDIN2J CHARGES ness and Professions Code, and my license is in full force and effect. ,` 'p 4, !' CONTRACTOR e.�_� CO ECTION CHARGE FEE License Number"'i -7 1 / J y Lic.Class I ADD �- r IMBURSEMENT FEE a s O BK PG CaniraClOr✓�I+%_ �Y`sS� Date 6 LAS 4 }�1 DISTRICT NO GROUP MAP PROCESSED BY E O+ � ` A,-2, O ❑ I am exempt under Sec. of the L.A.Co. TATE No. I 1 g ansS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE r VALIDATION W PUBLIC SEWER Q. B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD ate HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM +� Signature - CONNECT ADDITIONAL BLDG.OR Poo-OWNER-BUI DER DECLAR TION WORK TO HOUSE SEWER p OVERFLOW SEEPAGE PIT,DRAINFIELD .9 9 0 6 4 I herebyaffirm that I am exem t from the Contractor's License EXTN.,CESSPOOL,DRVWEIL,MANHOLE Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 0 0 o 0 fessions Code): SEWER OR DISPOSAL SYSTEM ) I o 1 54, 00 ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure o 4a 1 5 U, 0 0 c=.-, is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ o2,26-88 ❑ I,OS owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THISY '19— for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County Ordinan and tate laws r gulating Plumbing and Sewers, and reby out oriz e e ntatives of this County to enter up The above me ione operty for inspection purposes. I1 -� 4 ig ture of Permitte J D to SEE REVERSE FOR EXPLANATORY LANGUAGE l ''V r V yyy WORKEVS'.COMPENSATION DECLARATION • i afflrrrti that I have a certificate of consent to self 76A642D DPW 3/87 - nsure, r a certificate of Workers'Compensation Insurance, 6A642 a certified co y thereof(Sec 3800 CE BOB APPLICATION FOR PERMIT Policy t _Compony es ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed w�thnt bu di I s ection COUNTY OF LOS ANGELES BUILDING AND SAFETY de a ment Date ZS Appllca FOR APPLICANT TO FILL IN CONNECTION DATA CER IFICATE OF EXEMPTION FROM WORKERS' _ BUILDING . COMPENSATION INSURANCE ADDRESS Qy�� STATION -3J,b DEPTH / (This section need riot be completed)f the work Involved by the LOCALITY MANHOLE REFERENCE I P permit is for one hundredidollars ($100)or less.) r LOWER NEARI certify that In the performance of the work for which this CROSES T /'�' TYPE OF CONNECTION MIL TOP L permit is Issued, I shall not employ any person in any manner 4— Y CURB P L MIL TOP L so as to become subject to the Workers'Compensation Laws. OWNER CO IMP NO JOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant, ADDRESS 12f; -0-- NOTICE TO APPLICANT-, If, after making is Certificate othis f CITY TEL NO. 7 y��� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE "l V Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed " revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE OF LOT NOW ON LOT 1 hereby affirm that I am licensed under provisions ofChapter l BIJE �� USOF 9 (commenting with Section 7000) of Division 3 of the Busi- O ness and Professions Code, and my license is in full force and CHARGES effect , CONTR CTOR NECTION CHARGE FEE License Number �1� Lic Class a i IMBURSEMENT FEE O Contracto to DISTRICT NO G UP MAP PROCESSED BY V -j B PG Z El am exempt under Seco, the L.A Co LICENSE NO CLIC s ✓�f� J 0 Plumbing Code and/or Sec. of the No T OF FINAL �� ON LU PUBLIC SEWER C� SE SEW R C NE I � DATE � " VALIDA B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR CO PITS AND/OR DRAINFIELD FI Z Dat HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM / Signature CONNECT ADDITIONAL BLDG OR ER-BUIL ER DECLARATI N WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 2 9 0 6 0 A Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM _ El 1,as owner of the property,or my employees with wages as # 0 p o O .0 their sole compensation, will do the work and the structure _ ' I2750 0 0 is not Intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ o ko 0 2 7. rJ 0 U ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 022 b -8 8 Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC'SEWER CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS' D OF 19V for the performance of the work for which this permit is OWNER OR issued (Sec 3097, Civ C ) OWNERS AGE _ ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above infg.Lmation is Correct I agree to comply with all County ordin es and Stat "la s r gulating Plumbing and Sewers, a hereby au or' e r s ntativeS of this County to enter pon the abov - entio operty for inspection purposes Si nature of Per - ee ate G SEE REVERSE FOR EXPLANATORY LANGUAGE 4� 1:�t_ OAJ:� O P